Therapy Waitlist Registration Form
Client Full Name
*
First Name
Last Name
Client Date of Birth
-
Day
-
Month
Year
Date
Contact Full Name (e.g., parent)
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
How did you hear about us?
Please Select
Word of Mouth
Internet
Previous client
Perth Kids Hub
Other
Please Specify
Reason/s for therapy:
Please advise how you will pay for services:
*
NDIS
Medicare/Mental Health Care Plan - rebate plus gap payment
Private fee paying
Submit
Should be Empty: